OIG-18-78 - USCIS' Medical Admissibility Screening Process Needs
ImprovementSeptember 21, 2018 OIG-18-78
Process Needs Improvement
September 21, 2018
Why We Did This Audit USCIS is responsible for verifying that
foreign nationals applying for lawful permanent resident status
meet health-related standards for admissibility. We performed this
audit to determine whether USCIS has controls in place to ensure it
complies with these standards.
What We Recommend We made eight recommendations that, when
implemented, will improve USCIS’ selection and oversight of
physicians and its review of foreign nationals’ medical
forms.
For Further Information: Contact our Office of Public Affairs at
(202) 981-6000, or email us at
[email protected]
What We Found U.S. Citizenship and Immigration Services (USCIS) has
inadequate controls for verifying that foreign nationals seeking
lawful permanent residence status meet health-related standards for
admissibility. First, USCIS is not properly vetting the physicians
it designates to conduct required medical examinations of these
foreign nationals, and it has designated physicians with a history
of patient abuse or a criminal record. This is occurring because
USCIS does not have policies to ensure only suitable physicians are
designated. Second, when reviewing these foreign nationals’
required medical forms, USCIS Immigration Services Officers, are
accepting incomplete and inaccurate forms because they are not
adequately trained and because USCIS does not enforce its existing
policies.
As a result of these deficiencies, USCIS may be placing foreign
nationals at risk of abuse by physicians performing medical
examinations. USCIS could also be exposing the U.S. population to
contagious or dangerous health conditions from foreign nationals
erroneously granted lawful permanent resident status.
USCIS Response USCIS concurred with the eight recommendations and
described corrective action to implement them. We consider seven of
the recommendations resolved, and one recommendation is unresolved
pending USCIS reconsidering options for corrective action that were
discussed after the draft report was issued. All recommendations
remain open.
www.oig.dhs.gov OIG-18-78
Washington, DC 20528 / www.oig.dhs.gov
September 21, 2018
MEMORANDUM FOR: The Honorable L. Francis Cissna Director U.S.
Citizenship and Immigration Services
FROM: John V. Kelly Senior Official Performing the Duties of the
Inspector General
SUBJECT: USCIS’ Medical Admissibility Screening Process Needs
Improvement
Attached for your action is our final report, USCIS’ Medical
Admissibility Screening Process Needs Improvement. We incorporated
the formal comments from the U.S. Citizenship and Immigration
Services in the final report.
The report contains eight recommendations aimed at improving USCIS’
selection and oversight of physicians and its review of foreign
nationals’ medical forms. Your office concurred with the eight
recommendations and described corrective actions to implement them.
Based on information provided in your response to the draft report,
we consider recommendation 4 open and unresolved. As prescribed by
the Department of Homeland Security Directive 077-01, Follow-Up and
Resolutions for the Office of Inspector General Report
Recommendations, within 90 days of the date of this memorandum,
please provide our office with a written response that includes
your (1) agreement or disagreement, (2) corrective action plan, and
(3) target completion date for each recommendation. Also, please
include responsible parties and any other supporting documentation
necessary to inform us about the current status of the
recommendation. Until your response is received and evaluated, the
recommendation will be considered open and unresolved.
Based on information provided in your response to the draft report,
we consider recommendations 1 through 3 and 5 through 8 open and
resolved. Once your office has fully implemented the
recommendations, please submit a formal closeout letter to us
within 30 days so that we may close the recommendations. The
memorandum should be accompanied by evidence of completion of
agreed-upon corrective actions and of the disposition of any
monetary amounts.
Please send your response or closure request to
[email protected].
Consistent with our responsibility under the Inspector General Act,
we will provide copies of our report to congressional committees
with oversight and appropriation responsibility over the Department
of Homeland Security. We will post the report on our website for
public dissemination.
Please call me with any questions, or your staff may contact Sondra
McCauley, Acting Assistant Inspector General for Audits, at (202)
981-6000.
Table of Contents
Results of Audit
..............................................................................................
4
USCIS Does Not Properly Vet Physicians It Designates as Civil
Surgeons
................................................................................
4
USCIS’ Review of Medical Forms Is Inadequate
.................................... 11
Recommendations
.......................................................................................
14
Appendix B: USCIS Comments to the Draft Report
.............................. 23
Appendix C: Office of Audits Major Contributors to This Report
........... 28
Appendix D: Report Distribution
.......................................................... 29
Abbreviations
A-files Alien files CDC Centers for Disease Control and Prevention
CFR Code of Federal Regulations HHS Health and Human Services INA
Immigration and Nationality Act ISO Immigration Services Officer
LEIE List of Excluded Individuals and Entities MQRR Medical Quality
and Risk Reduction NPDB National Practitioner Data Bank NPWR
National Processing Workflow Repository OIG Office of Inspector
General U.S.C. United States Code USCIS U.S. Citizenship and
Immigration Services
www.oig.dhs.gov OIG-18-78
Background
U.S. Citizenship and Immigration Services (USCIS) administers the
Nation’s lawful immigration system, safeguarding its integrity and
promise by efficiently and fairly adjudicating requests for
immigration benefits while protecting Americans, securing the
homeland, and honoring our values.
As part of its mission, USCIS reviews and adjudicates the
applications of foreign nationals who legally enter the United
States and want to adjust from a temporary status to a lawful
permanent resident status. USCIS has the authority to determine a
foreign national’s admissibility to the United States; according to
the Immigration and Nationality Act (INA), immigrants who seek to
adjust their status may be inadmissible based on health-related
grounds, which are designed to protect the health of the U.S.
population.1
When applying for adjustment of status, foreign nationals are
required to undergo a medical examination by a physician whom USCIS
has designated as a civil surgeon. Physicians apply to USCIS for
designation as civil surgeons by submitting an Application for
Civil Surgeon Designation (Form I-910). Civil surgeons do not
determine a foreign national’s admissibility or eligibility for
immigration status adjustment; they perform the required medical
examination and report the findings on a Report of Medical
Examination and Vaccination Record (Form I-693) (medical form). The
civil surgeon provides the sealed, completed medical form to the
applicant, who then provides it to USCIS.
Prior to March 11, 2014, individual USCIS field offices were
responsible for determining whether a physician met the
requirements to be designated as a civil surgeon. When the program
was centralized in March 2014, USCIS “grandfathered” more than
4,200 civil surgeons, thereby allowing them to maintain their
designation without completing a Form I-910 for further
verification. Since March 11, 2014, Immigration Services Officers
(ISO) at USCIS’ National Benefits Center review and adjudicate
Forms I-910.
1 8 United States Code (U.S.C.) § 1182(a)(1)
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Figure 1 shows USCIS’ process for designating physicians as civil
surgeons.
Figure 1. USCIS’ Process for Designating Civil Surgeons, as of
March 11, 2014
Source: Department of Homeland Security Office of Inspector General
(OIG) representation of USCIS data
Foreign nationals who legally enter the United States may apply to
adjust to lawful permanent resident status by submitting an
Application to Register Permanent Residence or Adjust Status (Form
I-485) to USCIS.
ISOs at USCIS field offices and service centers review and
adjudicate applications for status adjustment. ISOs make the status
adjustment determination after reviewing the application (Form
I-485) and supporting documents, including the civil surgeon’s
report on the medical form. ISOs review the medical form to
determine whether the foreign national meets the health-related
standards for admissibility. The medical form should contain the
results of the civil surgeon’s medical examination and
documentation of any health concerns that may make the foreign
national inadmissible. According to the INA, the following four
medical conditions may make a foreign national inadmissible on
health related grounds:
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• communicable diseases of public health significance (e.g.,
gonorrhea, leprosy, and tuberculosis);
• failure to show proof of required vaccinations (e.g., polio,
varicella, and hepatitis A and B);
• physical or mental disorders with associated harmful behavior as
defined in the Diagnostic and Statistical Manual of Mental
Disorders; and
• drug abuse or addiction.
Figure 2 shows USCIS’ medical form review process, which is used to
verify the medical admissibility of foreign nationals seeking to
adjust to lawful permanent resident status.
Figure 2. USCIS’ Medical Form Review Process
Source: DHS OIG representation of USCIS data
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
In this report, we examine USCIS’ process for designating
physicians as civil surgeons and USCIS’ review of the medical forms
of foreign nationals applying to adjust to lawful permanent
resident status.
Results of Audit
USCIS has inadequate controls for verifying that foreign nationals
seeking lawful permanent residence status meet health-related
standards for admissibility. First, USCIS is not properly vetting
the physicians it designates as civil surgeons. We determined that
USCIS designated physicians with a history of patient abuse or a
criminal record as civil surgeons. This is occurring because USCIS
does not have adequate policies to ensure only suitable physicians
are designated as civil surgeons. Second, when reviewing these
foreign nationals’ required medical forms, ISOs are accepting
incomplete and inaccurate forms because they are not adequately
trained and because USCIS is not enforcing its existing
policies.
As a result of these deficiencies, USCIS may be placing foreign
nationals at risk of abuse by some civil surgeons. USCIS could also
be exposing the U.S. population to contagious or dangerous health
conditions from foreign nationals erroneously granted lawful
permanent resident status.
USCIS Does Not Properly Vet Physicians It Designates as Civil
Surgeons
In vetting physicians who apply to become civil surgeons, USCIS
neither ensures the physicians meet eligibility requirements for
designation as civil surgeons, nor has it prevented physicians with
a history of patient abuse or criminal records from being
designated as civil surgeons. In addition, USCIS allowed physicians
to remain civil surgeons without verifying that they met
eligibility requirements, and it does not always promptly revoke
the designation of noncompliant civil surgeons. These deficiencies
occurred because USCIS lacks policies and procedures to ensure
civil surgeons meet and maintain professional requirements. As a
result, USCIS could be risking the health and safety of foreign
nationals applying for lawful permanent residence.
USCIS Does Not Ensure Physicians Meet Civil Surgeon Eligibility
Requirements
The INA gives USCIS the authority to designate civil surgeons to
conduct medical examinations of foreign nationals seeking
immigration benefits, and the Code of Federal Regulations (CFR)2
provides general requirements for determining civil surgeon
eligibility. According to the INA and the CFR, only licensed
physicians with at least 4 years of professional experience may
be
2 8 C.F.R. § 232.2 (2017).
www.oig.dhs.gov 4 OIG-18-78
designated as civil surgeons. The USCIS Policy Manual (policy
manual) provides more specific requirements for determining civil
surgeon eligibility.3 According to the policy manual, an
application for civil surgeon designation must contain:
a completed Form I-910; proof of U.S. citizenship, legal status, or
authorization to work in the
United States; a copy of the physician’s medical degree verifying
he or she is a Doctor of
Medicine or Doctor of Osteopathy; a copy of the physician’s current
full and unrestricted medical license in
the state in which he or she seeks to perform immigration medical
examinations; and
evidence to verify the requisite professional experience, such as
letters of employment verification.
USCIS ISOs do not ensure that the physicians’ applications they
review comply with requirements in the INA, CFR, and the policy
manual. Specifically, we statistically sampled and reviewed 135
I-910 files of civil surgeons approved by USCIS between March 11,
2014, and June 30, 2017. For 19 of these 135 files (14 percent),
USCIS did not have the evidence to prove a physician met the
qualifications for a civil surgeon, with several of the 19 files
missing more than 1 piece of evidence. Table 1 shows the evidence
missing from the approved civil surgeons’ files.
Table 1. Evidence Missing from 19 I-910 Files of Approved Civil
Surgeons
Type of Evidence Missing from File Number of Files with
Evidence
Missing*
Required sections on the I-910 Form completed 5 Proof of
authorization to work in the United States 2 Copy of the
physician’s medical degree 6 Copy of the physician’s medical
license 1 Evidence of requisite (4 years) professional experience 9
Source: DHS OIG analysis of reviewed I-910 files
*The number of files adds up to more than 19 because some files
were missing more than 1 type of evidence.
Based on the results of our statistical sample, approximately 14
percent of the 1,337 civil surgeon designations, or an estimated
188 designations of the civil surgeon designation population, made
between March 11, 2014, and June 30, 2017, may lack evidence to
support USCIS’ decision to designate the physician as a civil
surgeon.
3 USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
These I-910 review process deficiencies occurred because USCIS does
not provide formal training to ISOs responsible for adjudicating
civil surgeon applications and does not require second-level
reviews. According to USCIS officials, one reason they do not
provide formal training is that only 1 or 2 ISOs are assigned to
review about 50 civil surgeon applications a month.
USCIS Designates Civil Surgeons Who May Put Foreign Nationals’
Health and Safety at Risk
In addition to designating physicians who may not meet eligibility
requirements, USCIS failed to prevent physicians with a history of
patient abuse or a criminal record from being designated as civil
surgeons. We attribute this failure to inadequate reviews of
physicians’ histories. Specifically, USCIS does not require ISOs to
consider medical board disciplinary history before designating
physicians as civil surgeons.
Of USCIS’ 5,569 active civil surgeons, 132 could pose a health or
safety risk to foreign nationals seeking to adjust their status.4
We identified 11 civil surgeons, active as of June 30, 2017, who
had been excluded by the Department of Health and Human Services
(HHS) OIG from participating in federally funded health care
programs for various offenses. These 11 physicians were on HHS
OIG’s List of Excluded Individuals and Entities (LEIE), a public
list of individuals and entities excluded from participation in
Medicare, Medicaid, and all other Federal health care programs.
Although USCIS’ civil surgeons are not part of a federally funded
health care program, they are the only physicians USCIS authorizes
to conduct immigration-related medical examinations and to complete
medical forms. As shown in table 2, these 11 physicians’ offenses
ranged from convictions related to fraud, patient abuse, and
neglect to exclusion or suspension from health care programs.
Table 2. Offenses of Physicians Excluded from Federally Funded
Health Care Programs
Number of Civil Categories of Excludable Offenses Surgeons
Conviction relating to program or health care fraud 1 Default on
health education loan or scholarship 2 Federal or state health care
program exclusion or suspension 4 Patient abuse or neglect
conviction 1 Program-related conviction 3 Total number of civil
surgeons excluded from federally 11funded health care
programs
Source: DHS OIG analysis of LEIE as of July 2017 and active civil
surgeons as of June 30,
4 There were 5,569 total active civil surgeons as of June 30,
2017.
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
Additionally, state medical boards have disciplined 121 active
civil surgeons for offenses that may meet HHS OIG’s criteria for
exclusion. Twenty-nine of the 121 civil surgeons had disciplinary
actions for egregious infractions. These offenses include felony
conviction for solicitation of capital murder and engaging in
dishonest, gross, and repeated negligent conduct in patient care
and treatment. Although some disciplinary conduct may have occurred
years ago, the nature of the offense may continue to render these
physicians a risk to those applying for immigration benefits. For
example, USCIS designated the following physicians as civil
surgeons:
A physician in Georgia with a felony conviction for solicitation of
capital murder because he attempted to hire a hit man to kill a
dissatisfied patient in Houston, Texas. The California,
Pennsylvania, and Texas Medical Boards subsequently revoked his
license for the criminal conviction. However, the Georgia Medical
Board allowed the physician to resume his practice several years
later.
A physician with a history of professional sexual misconduct and
exploitation of female patients from a position of power,
authority, and trust. The Texas Medical Board restricted his
license for 5 years and the physician was not allowed to be alone
with female patients while conducting physical examinations.
A physician disciplined by the California Medical Board for
numerous offenses, including allowing her medical assistants to
dilute mumps, measles, rubella, and varicella vaccines; pre-draw
vaccines; administer injections with less than effective needles;
give free vaccines to ineligible patients; falsify medical records;
and other unprofessional behaviors.
Although Federal laws and regulations give USCIS discretion in
designating physicians as civil surgeons, the component has
established only minimal eligibility requirements for physicians.
When they are determining whether to designate a physician as a
civil surgeon, USCIS does not require ISOs to consider a
physician’s medical board disciplinary history. Rather, USCIS
officials said ISOs only check the status of the medical license
the physician provided in the application. To guard against risking
the health and safety of these foreign nationals, USCIS should more
thoroughly scrutinize physicians before allowing them to become
civil surgeons.
DHS has a resource USCIS could use to better monitor physicians who
apply for designation as civil surgeons. The Medical Quality and
Risk Reduction Branch (MQRR) in DHS’ Workforce Health and Safety
Division is responsible for protecting national security and
mitigating liability by ensuring employees, detailees, and
contractors have the qualifications and other credentials (e.g.,
licenses) necessary to perform medical services for, or on behalf
of, DHS.
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
MQRR uses the National Practitioner Data Bank (NPDB) to verify and
continuously monitor medical provider credentials, including
qualifications, licensure information, and other relevant health
care provider data.5 Figure 3 shows the type of information
captured in the NPDB.
Figure 3. Types of Information in the National Practitioner Data
Bank
Source: https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp (last
visited May 30, 2018)
USCIS could use MQRR’s access to the NPDB to assess the suitability
of physicians who apply to become civil surgeons. MQRR could notify
USCIS of
5 Congress created the NPDB as an information clearinghouse, with
the primary goals of improving health care quality, protecting the
public, and reducing health care fraud and abuse in the United
States.
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
physicians who may not meet DHS suitability standards and may pose
a risk to foreign nationals or national security.
USCIS Allowed Civil Surgeons to Maintain Their Designation without
Verifying Their Eligibility
Prior to March 11, 2014, USCIS field offices designated physicians
as civil surgeons. In March 2014, USCIS centralized the civil
surgeon program and introduced the I-910 process, at which time the
component “grandfathered” more than 4,200 civil surgeons, thereby
allowing them to maintain their designation without verifying they
met eligibility requirements.6 According to USCIS officials, these
civil surgeons were not required to complete a Form I-910.
Our review of 25 active grandfathered civil surgeon files showed
that USCIS did not have the evidence necessary to support their
designations. Specifically, USCIS did not have a file to support
the designation of 4 of the grandfathered civil surgeons, and all
21 of the remaining civil surgeon files were missing 1 or more
types of evidence required by the policy manual.7 Table 3 shows the
evidence missing to support the grandfathered civil surgeon
designations.
Table 3. Evidence Missing from 25 Grandfathered Civil Surgeon
Designations
Type of Evidence Missing Number of Files with evidence
missing*
Proof of authorization to work in the United States 10 Copy of the
physician’s medical degree 17 Copy of the physician’s medical
license 3 Evidence of requisite professional experience 21 Entire
file missing 4 Source: DHS OIG analysis of reviewed grandfathered
civil surgeon files
*The number of files adds up to more than 25 because some files
were missing more than 1 type of evidence.
This deficiency occurred because, prior to March 11, 2014, when
field offices were designating physicians as civil surgeons, USCIS
did not have formal policies requiring evidence to support their
designation. Also, when the designation process was centralized,
USCIS officials stated they did not ask the more than 4,200
grandfathered civil surgeons to provide evidence verifying they met
the eligibility requirements.
6 We did not include USCIS’ decision to grandfather civil surgeons
designated prior to the initiation of the I-910 process in the
scope of this audit and take no position on the legality or
propriety of USCIS’ decision. 7 USCIS Policy Manual, Volume 8, Part
C, Chapter 2, Section B
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
USCIS Did Not Take Prompt Action against Civil Surgeons Who Failed
to Maintain a Current and Unrestricted Medical License
Revoking a physician’s designation as a civil surgeon makes him or
her ineligible to conduct immigration-related medical examinations.
According to the policy manual and Form I-910 instructions, USCIS
may revoke a civil surgeon’s designation for several reasons,
including failure to:
maintain a currently valid and unrestricted license to practice as
a physician in any state in which the physician conducts
immigration-related medical examinations;
comply with Centers for Disease Control and Prevention (CDC)
Technical Instructions for Panel Physicians and Civil Surgeons
(technical instructions);8
and continue to meet the professional qualifications required for
civil surgeon
designation, engaging in immigration fraud, or otherwise engaging
in activity that poses a risk to public health or safety. According
to USCIS regulations, a form's instructions are incorporated into
the regulations requiring its submission [8 CFR
§103.2(a)(1)].
In reviewing a report that USCIS received in May 2017 on active
civil surgeons, we identified 48 civil surgeons, who were not in
our statistical sample and whose medical license was either expired
or restricted. Although USCIS received the report in May 2017,
several months elapsed before the component revoked the
designations of 37 of the 48 civil surgeons. For the 37 civil
surgeons, USCIS revoked 1 designation in July 2017, 34 designations
in August 2017, and 1 designation in November 2017.9 As of December
2017, the other remaining 11 civil surgeons were active and able to
conduct medical examinations while USCIS reviewed their medical
license status.
USCIS did not promptly revoke these designations because its
process for identifying civil surgeons with inactive or restricted
medical licenses is inefficient. According to USCIS officials, to
determine whether civil surgeons should maintain their designation,
USCIS checks the status of their medical license using a
contractor, Evercheck, which is only required to verify medical
license information on active civil surgeons biannually (every 6
months). Further, one ISO is responsible for manually reviewing
Evercheck’s biannual report and determining whether a civil
surgeon’s medical license is compliant. According to USCIS
officials, the review requires considerable effort and time
8 CDC’s Technical Instructions for Panel Physicians and Civil
Surgeons are on the CDC website and include instructions on
recording findings from the medical examination and on
vaccinations, medical history, and communicable diseases. (See
https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil
surgeons.html, (last visited June 15, 2018). 9 One civil surgeon
voluntarily relinquished the designation in August 2017.
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
because the biannual report contains medical license information
for more than 5,500 civil surgeons.
In addition to using the NPDB to monitor physicians applying to
become civil surgeons (as noted previously), the NPDB may be
another resource to monitor civil surgeons’ medical licenses. MQRR
could notify USCIS of negative actions against civil surgeons’
medical licenses reported in NPDB, and this information could
facilitate USCIS’ revocations.
USCIS’ Review of Medical Forms Is Inadequate
As part of adjudicating applications to adjust to lawful permanent
resident status, ISOs review medical forms to verify foreign
nationals meet health- related standards for admissibility. We
reviewed 151 statistically sampled Alien files (A-files)10 of
foreign nationals whom USCIS had approved for lawful permanent
resident status. We identified errors in 44 of the medical forms in
these A-files. Some errors were caused by ISOs accepting incomplete
and inaccurate medical forms. In other cases, the forms were
completed and signed, but ISOs did not verify that the civil
surgeon who signed the form was active. Finally, in some instances,
civil surgeons did not follow CDC’s technical instructions.11
These deficiencies occurred because USCIS did not adequately train
ISOs on proper review of medical forms and USCIS did not enforce
its existing policy, which requires ISOs to return inaccurate
medical forms to the foreign national for corrective action. Also,
USCIS does not review and track errors on medical forms to monitor
how well civil surgeons comply with CDC’s technical instructions.
As a result, USCIS cannot be certain the civil surgeons actually
administered all required tests and vaccinations and may have
granted lawful permanent residence status to medically inadmissible
foreign nationals who could pose a health risk to the U.S.
population.
ISOs Accepted Incomplete and Inaccurate Medical Forms
When adjudicating foreign nationals’ status adjustment
applications, ISOs are required to determine a foreign national’s
medical admissibility based on the information in the medical form.
According to USCIS policy, when determining medical admissibility,
ISOs must ensure medical forms are legible, complete, valid, signed
and dated, and placed in a sealed envelope. If these requirements
are not met, ISOs must return the medical form to the foreign
national for
10 A-files are the official files for immigration and
naturalization records created or consolidated for non-U.S.
citizens. 11 We attributed some of the same errors on medical forms
to two or even three causes. For example, an ISO may have accepted
an incomplete or inaccurate form, in which the civil surgeon also
failed to follow CDC’s technical instructions. For this reason, the
number of errors we identified exceeds the number of medical
forms.
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
corrective action.12 ISOs may suspend their decision on the
adjustment of status until a complete and accurate medical form is
resubmitted. Also according to the policy manual, ISOs may grant a
waiver for certain vaccinations, for example, if the foreign
national has had a severe allergic reaction to a vaccination.
In 32 of 151 A-files reviewed, ISOs did not comply with USCIS
policy when reviewing medical forms and accepted incomplete or
inaccurate medical forms. We identified the following errors:
19 medical forms missing vaccination information or in which the
civil surgeon marked the wrong box on the vaccination portion of
the form.
5 medical forms missing required medical tests, such as tests for
gonorrhea or syphilis.
7 medical forms with various errors, such as the form was not
signed by an active civil surgeon, the form had expired (requiring
a new form), the civil surgeon signed the form before receiving
test results, the civil surgeon did not verify the foreign
national’s identity, or the form did not contain the required stamp
from a health department.
1 medical form in which the civil surgeon’s information was not
legible.
Based on our statistical sample results, from October 2013 through
May 2017, USCIS may have approved about 330,000 of 1,558,031
adjustment of status applications population with inaccurate or
incomplete medical forms. These errors may have rendered the
foreign nationals medically inadmissible.
This acceptance of invalid medical forms occurred because USCIS
does not adequately train ISOs on reviewing medical forms to
determine whether the foreign national meets health-related
standards for admissibility. When hired, USCIS provides new ISOs
with fewer than 2 hours of training focused on health-related
admissibility standards or on reviewing medical forms — out of 200
total training hours. For ISOs reviewing applications that do not
require an in-person interview, USCIS provides up to 5 hours of
total training focused on health-related admissibility standards.
USCIS also did not maintain a record to demonstrate how often such
training occurs and does not have a system in place to ensure ISOs
receive annual training.
ISOs Did Not Verify That Active Civil Surgeons Completed Medical
Forms
USCIS policy requires foreign nationals’ medical forms be signed
and dated by an active civil surgeon who conducted the medical
examination, but does not
12 USCIS Policy Manual, Volume 8, Part B, Chapter 4
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
require ISOs to verify the civil surgeon’s signature or whether the
civil surgeon was active at the time of the examination. The policy
manual13 only states that an ISO “should consult” the Find a Doctor
tool on USCIS’ website14 to determine whether the physician is a
designated civil surgeon.
For 11 of the 151 A-files we reviewed USCIS could not demonstrate
that an active civil surgeon completed the form. In these 11
A-files, either the civil surgeon’s signature on the medical form
did not match USCIS’ records or the civil surgeon was not in USCIS’
internal system of civil surgeon information, the National
Processing Workflow Repository (NPWR). Based on our statistical
sample results, nearly 110,000 of 1,558,031 population of A-files
approved from October 2013 through May 2017 may have similar
errors.
Rather than consulting Find a Doctor, ISOs could use NPWR to
validate a civil surgeon’s status and signature when reviewing
medical forms. Find a Doctor contains the civil surgeon’s office
information, but it does not contain images of signatures or the
dates a physician has been an active civil surgeon. NPWR contains
more information on civil surgeons, such as status and designation
date, signature,15 and, if applicable, periods of inactivity.
However, USCIS does not require ISOs to use NPWR. As of October
2017, only 658 of 6,226 ISOs had access to the system.
USCIS officials said ISOs who do not have access to NPWR rely on
their familiarity with civil surgeons in their geographic location
and on Find a Doctor. However, neither method allows ISOs to fully
substantiate a civil surgeon’s information or verify that active
civil surgeons are signing and dating medical forms. USCIS has
advertised NPWR’s usefulness to several USCIS field offices and
suggested ISOs request access.
Civil Surgeons Did Not Follow CDC’s Technical Instructions
Civil surgeons must follow CDC’s technical instructions for
conducting medical examinations and filling out medical forms;
failure to comply with the instructions is grounds for revoking
civil surgeon designation. USCIS is not reviewing and tracking
errors on medical forms to monitor civil surgeons’ compliance with
the technical instructions. This occurred because Federal
regulations do not specify that USCIS monitor and oversee civil
surgeons. Consequently, civil surgeons may not receive proper
instruction. USCIS also cannot effectively seek revocation of civil
surgeons who fail to accurately complete medical forms or determine
whether civil surgeons are administering required vaccinations and
tests.
13 USCIS Policy Manual, Volume 8, Part B, Chapter 4. 14 The Find a
Doctor tool is on the USCIS website at
https://my.uscis.gov/findadoctor (last visited June 15, 2018).
Foreign nationals may use this tool to locate a civil surgeon. 15
NPWR does not contain images of every civil surgeon’s
signature.
www.oig.dhs.gov 13 OIG-18-78
OFFICE OF INSPECTOR GENERAL Department of Homeland Security
Of the 151 A-files reviewed, 28 contained medical forms in which
the civil surgeon did not follow CDC’s technical instructions for
completing the form. These errors included no evidence of testing
the foreign national for gonorrhea and missing or incorrectly
marked vaccinations. As stated previously, ISOs accepted medical
forms with this missing or inaccurate information.
Some of the missing information could indicate civil surgeons did
not administer required tests and vaccinations, which may mean some
foreign nationals did not meet health-related standards for
admissibility. For example, according to the CDC, having gonorrhea
is grounds for inadmissibility. In addition, the CDC’s Vaccination
Technical Instructions for Civil Surgeons require civil surgeons,
among other things, to administer required vaccines, such as those
for polio, hepatitis B, varicella, and influenza, to those applying
for status adjustment. Based on our statistical sample results,
nearly 289,000 of the population of 1,558,031 A-files approved from
October 2013 through May 2017 may have similar errors.
According to the Government Accountability Office, management
should establish and operate activities to monitor its internal
control system and evaluate the results,16 but USCIS has done
neither. According to USCIS, it is not responsible for monitoring
civil surgeons. USCIS officials also informed us that the component
does not have a process to monitor civil surgeons’ compliance with
CDC technical instructions for completing immigration-related
medical forms, even though failure to comply with these
instructions is grounds for revoking USCIS designation as a civil
surgeon.
Recommendations
Recommendation 1: We recommend the USCIS Chief of the Regulatory
Coordination Division for the Office of Policy and Strategy develop
stricter ineligibility requirements for civil surgeon designations,
which could include standards used by the Department of Health and
Human Services Office of Inspector General, and implement processes
to strengthen the vetting process of physicians and active civil
surgeons.
Recommendation 2: We recommend the Associate Director for the Field
Operations Directorate:
a. establish a training regimen for personnel responsible for
adjudicating civil surgeon applications; and
b. establish quality control reviews of civil surgeon application
decisions.
16 Principle 16 of Government Accountability Office Standards for
Internal Control in the Federal Government
www.oig.dhs.gov 14 OIG-18-78
Recommendation 3: We recommend the Associate Director for the Field
Operations Directorate review grandfathered civil surgeons to
confirm that they meet current eligibility requirements, and that
USCIS maintain all required documents. At a minimum, the
eligibility requirements should include:
a. prompt review and identification of noncompliant civil surgeons;
b. issuance of Intent to Revoke notices within 30 days of
identification; and c. re-evaluation of active civil surgeons to
determine whether they meet the
newly developed requirements.
Recommendation 4: We recommend the Associate Director for the Field
Operations Directorate evaluate the Medical Quality and Risk
Reduction Branch services and implement applicable services to
assist USCIS in making its civil surgeon determinations.
Recommendation 5: We recommend the Director for USCIS strengthen
its training program on health admissibility by:
a. providing focused training on what the USCIS Policy Manual
considers a complete and accurate medical form; and
b. developing a schedule for recurrent training for Immigration
Services Officers, at least annually.
Recommendation 6: We recommend the Associate Director for Field
Operations Directorate establish a quality control process to
ensure that Immigration Services Officers only accept complete and
accurate medical forms, as required by written policy.
Recommendation 7: We recommend the Office of Policy and Strategy
update the USCIS Policy Manual so Immigration Services Officers are
required to verify the authenticity of the civil surgeon’s
information, such as signature and designation status, on the
medical form.
Recommendation 8: We recommend the Associate Director for Field
Operations Directorate establish a process to track civil surgeon
medical form errors to identify areas that need improvement. The
process should include:
a. tracking civil surgeons’ accuracy in complying with CDC’s
Technical Instructions for Panel Physicians and Civil
Surgeons;
b. tracking the completeness of the forms; and c. establishing a
system to ensure civil surgeons understand and follow the
CDC’s Technical Instructions for Panel Physicians and Civil
Surgeons and to ensure civil surgeons who fail to fulfill their
responsibilities face prompt revocation.
www.oig.dhs.gov 15 OIG-18-78
Management Comments and OIG Analysis
USCIS concurred with our eight recommendations. We included a copy
of the USCIS management comments in their entirety in appendix B.
We also received technical comments to the draft report and made
revisions to the report as appropriate. We consider seven
recommendations to be resolved and open until USCIS implements the
proposed corrective actions. Recommendation 4 is unresolved pending
USCIS evaluating implementation options presented after the draft
was issued. A summary of USCIS’ response and our analysis
follows.
USCIS Response to Recommendation #1: Concur. USCIS agreed that
stricter eligibility requirements for civil surgeon designation and
a strengthened vetting process will improve the quality and
integrity of the program. USCIS’ Office of Policy and Strategy will
lead a working group to evaluate current requirements and pursue
regulatory amendments that would establish additional requirements
that would enhance the program’s integrity. The group will also
examine the feasibility of establishing an audit process to assess
how well civil surgeons are complying with USCIS requirements and
Technical Instructions for conducting the medical exam. USCIS
anticipates completing actions to implement this recommendation by
December 31, 2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we evaluate the results of the working group
and verify USCIS has implemented stricter eligibility requirements
and strengthened the vetting process.
USCIS Response to Recommendation #2: Concur. The Director stated
that USCIS’ Field Operations Directorate personnel are in the
process of finalizing training materials for personnel responsible
for adjudicating civil surgeon applications. USCIS will also
establish a quality assurance program that will include a 100
percent review of newly trained officer’s work. USCIS anticipates
completing actions to implement this recommendation by March 31,
2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we review the revised training materials and
evaluate the effectiveness of the quality assurance program.
USCIS Response to Recommendation #3: Concur. USCIS plans to
implement a 100 percent review of active grandfathered civil
surgeon records to confirm they meet eligibility requirements. If
deficiencies are discovered, USCIS will issue a Request of Evidence
and/or Notice of Intent to Revoke to resolve the deficiency. To the
extent feasible, USCIS will issue the Notice of Intent to Revoke
within 30 days of identification of a noncompliant civil surgeon.
USCIS
www.oig.dhs.gov 16 OIG-18-78
anticipates completing actions to implement this recommendation by
March 31, 2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we review USCIS’ documentation supporting the
review of the grandfathered civil surgeons.
USCIS Response to Recommendation #4: Concur. The Director stated
that USCIS completed an evaluation of the MQRR Branch services and
determined that MQRR is not equipped to provide the services USCIS
requires in making its civil surgeon determinations. Specifically,
the Director stated that the NPDB does not validate medical
licenses; MQRR can input only 10 physicians per day; and MQRR can
only add or remove physicians on a quarterly basis. Based on these
actions, the Director requested that the OIG consider this
recommendation resolved and closed as implemented.
OIG Analysis: We consider these actions nonresponsive to the
recommendation, and they will remain unresolved and open. In
follow-on discussions between the OIG and MQRR officials, we
learned that MQRR is willing to work with USCIS to implement a
batch submission process for 1,000 physicians at a time, which
would drastically reduce the turnaround time. Further, MQRR
officials confirmed they add and remove medical providers from the
NPDB daily, and perform random credentialing records review to
assess the accuracy of the information on a quarterly basis. MQRR
did acknowledge that the NPDB does not validate medical licenses,
but stated the NPDB does collect negative actions on a provider’s
license. MQRR has committed to researching and reviewing medical
credentialing software to automate the state licensure verification
and the NPDB monitoring process. OIG shared this information with
USCIS after reviewing management’s technical comments to the draft
report. USCIS has since agreed to reconsider MQRR’s options. USCIS
has committed to providing an updated response within 90 days from
the issuance of the final report.
USCIS Response to Recommendation #5: Concur. The Director committed
to USCIS strengthening its training program on health admissibility
through a series of actions. Multiple USCIS directorates and
offices will work together to determine if training on the medical
form during the ISO Basic Training Program can be enhanced. If it
is determined that a more focused medical form training (i.e.,
increased training time) is feasible, USCIS would develop, review,
and implement new training materials. USCIS will also work to
develop an electronic training course on the medical form that new
officers would be required to take after completing the Basic
Training. This training would be available in the Department’s
Performance and Learning Management System and could also be
utilized as refresher training for officers, as needed. Once
www.oig.dhs.gov 17 OIG-18-78
OFFICE OF INSPECTOR GENERAL Department of Homeland Security
developed, the electronic medical form training course would be
made available to all officers and required annually for those
officers working on benefit types that require familiarity with
health admissibility. USCIS anticipates completing actions to
implement this recommendation by March 30, 2020.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we review USCIS’ documentation supporting the
new training material and course.
USCIS Response to Recommendation #6: Concur. USCIS agrees that a
quality control process for the medical forms will assist them in
accepting only complete and accurate medical forms. USCIS will
establish a quality control review process for the medical forms to
ensure compliance with written USCIS policy. USCIS will regularly
review its written policies on medical forms to ensure that they
comply with current CDC Technical Instructions. USCIS anticipates
completing actions to implement this recommendation by September
30, 2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we review USCIS’ quality control
process.
USCIS Response to Recommendation #7: Concur. The Director stated
that USCIS’ Office of Policy and Strategy, together with other
USCIS directorates, will examine the feasibility of requiring
officers to verify the authenticity of the civil surgeon’s
information in the record, including comparing signatures of civil
surgeons with their exemplar signatures contained in USCIS records,
as well as other information relating to a civil surgeon. If deemed
feasible, the Office of Policy and Strategy will revise the Policy
Manual, as appropriate. USCIS anticipates completing actions to
implement this recommendation by December 31, 2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. However, we recommend
USCIS take all necessary steps to implement a process requiring an
officer to follow policy ensuring foreign nationals’ medical forms
be signed and dated by an active civil surgeon. We will close this
recommendation after we review USCIS’ documentation on the
feasibility study and subsequent changes to the policy
manual.
USCIS Response to Recommendation #8: Concur. USCIS states it is
committed to developing and implementing a process that tracks
medical errors as well as being able to identify areas of
improvement. The creation of this process may entail the
development of new technology, which supports such tracking. In the
interim, officers may use the National Benefit Center’s Civil
Surgeons mailbox to report non-compliant civil surgeons. USCIS
will
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OFFICE OF INSPECTOR GENERAL Department of Homeland Security
consult with the Office of the Chief Counsel regarding revocation
of a civil surgeon who is failing to fulfill his or her
responsibilities. In addition, USCIS plans to aggregate the overall
I-693 errors and consult with the CDC on the best way to
communicate with civil surgeons so that it can ensure physicians
understand and follow the Technical Instructions, as well as the
consequences of not doing so. USCIS anticipates completing actions
to implement this recommendation by September 30, 2019.
OIG Analysis: We consider these actions responsive to the
recommendation, which is resolved and open. We will close this
recommendation after we review USCIS’ proposed process and the
results of any discussions with CDC.
www.oig.dhs.gov 19 OIG-18-78
Appendix A Objective, Scope, and Methodology
DHS OIG was established by the Homeland Security Act of 2002
(Public Law 107−296) by amendment to the Inspector General Act of
1978.
We performed this audit to determine whether USCIS has controls in
place to ensure foreign nationals meet health-related standards for
admissibility prior to granting lawful permanent resident status.
The scope of the audit includes a review of USCIS’ roles, policies,
and standard operating procedures. The scope period for this audit
was from October 2013 through June 2017.
To achieve our objective, we reviewed Federal and component
guidance on health-related standards for inadmissibility. We
interviewed officials from DHS offices — Citizenship and
Immigration Ombudsman, Civil Rights and Civil Liberties, and MQRR
Branch; and USCIS offices — Customer Service and Public Engagement,
Field Operations Directorate, Fraud Detection National Security,
National Benefits Center, Office of Chief Counsel, Office of Policy
and Strategy, and Service Center Operations Directorate. The team
also interviewed officials from the U.S. Department of State and
CDC to gain an understanding of the similarities or differences
between the medical examination process within the United States
and the medical examination process in foreign countries.
We performed site visits to the Texas Service Center in Dallas,
Texas; and the National Benefits Center in Lee’s Summit, Missouri,
to gain an understanding of USCIS’ review process for medical
examination forms related to adjustment of status and the civil
surgeon application review process.
We performed a limited review of the internal controls associated
with USCIS’ medical screening process. Specifically, we evaluated
USCIS compliance with Form I-910 applications and Form I-693
medical forms and compared them to USCIS policies and procedures.
The findings identified in this report can be adequately addressed
by implementation of our recommendations. In making these
recommendations, OIG acknowledges that to the extent we recommend
new policies, USCIS may be required to conduct formal rulemakings
pursuant to the Administrative Procedures Act, 5 U.S.C. §551 et
seq., applicable regulations, and judicial precedents.
www.oig.dhs.gov 20 OIG-18-78
Appendix A (cont.)
We performed a review to determine whether any civil surgeon active
as of June 30, 2017, appeared on HHS OIG’s LEIE. Furthermore, we
compared whether disciplinary actions for active civil surgeons
notated on Evercheck’s May 2017 report would meet the LEIE criteria
for exclusion if that surgeon participated in a federally funded
health care program. We retrieved medical board orders and
administrative hearing documents from the appropriate state medical
board websites.
Sampling Methodology
The team selected three samples: I-910 civil surgeon applicants,
grandfathered civil surgeons, and A-files. The civil surgeon and
the A-file data was retrieved from the Standard Management Analysis
Reporting Tool. Prior to selecting our samples, we tested the
reliability of component-generated data during fieldwork on the
Tool. We determined the information was sufficiently reliable to
support the audit’s conclusions. Each sample selection was
performed as follows:
I-910 Civil Surgeons — As of June 30, 2017, there were 1,337 active
civil surgeons who had completed the I-910 application. Assuming a
population proportion of 50 percent, with the population size of
1,337 active civil surgeons, the minimum sample size required for a
95 percent confidence level and allowable error of ± 8 percent is
135. This sample of 135 I-910 application files was randomly
selected with the help of IDEA software. To test for compliance
with USCIS civil surgeon professional requirements, we used the
sample results of these 135 I-910 files of active civil surgeons to
infer it to the population of 1,337 active civil surgeons.
Grandfathered Civil Surgeons — Our audit population was the number
of grandfathered civil surgeons who had active designations as of
June 30, 2017. At that time, USCIS had 4,232 grandfathered civil
surgeons. The team performed a random sample to assess the level of
documentation for professional requirements contained in the file.
We selected a judgmental sample size of 25 grandfathered civil
surgeons. We did not infer the results of this sample and only
reported on the 25 files reviewed.
Alien files — Our audit population was limited to A-files stored at
the National Records Center, retired or archived, that contained an
approved application to adjust status and a medical form
adjudicated from October 1, 2013, through May 31, 2017. We did not
include active A-files, even if they had adjusted status during our
scope period, to minimize disruptions to USCIS business, such as
being used for another USCIS process or a court case. The audit
population consisted of 1,558,031 A-files containing an approved
medical form
www.oig.dhs.gov 21 OIG-18-78
Appendix A (cont.)
and adjudicated between October 1, 2013, and May 31, 2017. Assuming
a population proportion of 50 percent, with the population size of
1,558,031 A-files, the minimum sample size required for a 95
percent confidence level and allowable error of ± 8 percent is 151.
This sample of 151 A-files was randomly selected with the help of
Excel software. To determine whether ISOs reviewed and processed
the medical forms according to USCIS policy, we used the sample
results of these 151 A-files to infer it to the population of
1,558,031 A-files.
This performance audit was conducted between February 2017 and
March 2018 pursuant to the Inspector General Act of 1978, as
amended, and according to generally accepted government auditing
standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based upon our
audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based upon our
audit objectives.
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Appendix C Office of Audits Major Contributors to This Report
Yesi Starinsky, Director Loretta Atkinson, Audit Manager Christine
Alvarez, Auditor in Charge Julian Brown, Auditor Victoria Buono,
Program Analyst Jennifer Eads, Program Analyst Mary Nowak, Auditor
Juan Santana, Auditor M. Faizul Islam, Ph.D. Statistician Kevin
Dolloson, Communications Analyst Kelly Herberger, Supervisory
Communications and Policy Analyst Gary Alvino, Independent
Reference Reviewer Brad Mosher, Independent Reference
Reviewer
www.oig.dhs.gov 28 OIG-18-78
Appendix D Report Distribution
Department of Homeland Security
Secretary Deputy Secretary Chief of Staff General Counsel Executive
Secretary Director, GAO/OIG Liaison Office Assistant Secretary for
Office of Policy Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs USCIS
Component Liaison
Office of Management and Budget
Chief, Homeland Security Branch DHS OIG Budget Examiner
Congress
www.oig.dhs.gov 29 OIG-18-78
Additional Information and Copies
To view this and any of our other reports, please visit our website
at: www.oig.dhs.gov.
For further information or questions, please contact Office of
Inspector General Public Affairs at:
[email protected]. Follow us on Twitter at:
@dhsoig.
OIG Hotline To report fraud, waste, or abuse, visit our website at
www.oig.dhs.gov and click on the red "Hotline" tab. If you cannot
access our website, call our hotline at (800) 323-8603, fax our
hotline at (202) 254-4297, or write to us at:
Department of Homeland Security Office of Inspector General, Mail
Stop 0305 Attention: Hotline 245 Murray Drive, SW Washington, DC
20528-0305
September 21, 2018 OIG-18-78
September 21, 2018 OIG-18-78
USCIS’ Medical Admissibility Screening .Process Needs Improvement
.
September 21, 2018 Why We Did This Audit USCIS is responsible for
verifying that foreign nationals applying for lawful permanent
resident status meet health-related standards for admissibility. We
performed this audit to determine whether USCIS has controls in
place to ensure it complies with these standards. What We Recommend
We made eight recommendations that, when implemented, will improve
USCIS’ selection and oversight of physicians and its review of
foreign nationals’ medical forms. For Further Informa
What We Found
What We Found
U.S. Citizenship and Immigration Services (USCIS) has inadequate
controls for verifying that foreign nationals seeking lawful
permanent residence status meet health-related standards for
admissibility. First, USCIS is not properly vetting the physicians
it designates to conduct required medical examinations of these
foreign nationals, and it has designated physicians with a history
of patient abuse or a criminal record. This is occurring because
USCIS does not have policies to ensure only suitable
physician
As a result of these deficiencies, USCIS may be placing foreign
nationals at risk of abuse by physicians performing medical
examinations. USCIS could also be exposing the U.S. population to
contagious or dangerous health conditions from foreign nationals
erroneously granted lawful permanent resident status.
USCIS Response
USCIS Response
USCIS concurred with the eight recommendations and described
corrective action to implement them. We consider seven of the
recommendations resolved, and one recommendation is unresolved
pending USCIS reconsidering options for corrective action that were
discussed after the draft report was issued. All recommendations
remain open.
OIG-18-78
www.oig.dhs.gov
September 21, 2018
MEMORANDUM FOR: .The Honorable L. Francis Cissna Director U.S.
Citizenship and Immigration Services FROM: .John V. Kelly Senior
Official Performing the Duties of the Inspector General SUBJECT:.
USCIS’ Medical Admissibility Screening Process Needs
Improvement
Attached for your action is our final report, USCIS’ Medical
Admissibility Screening Process Needs Improvement. We incorporated
the formal comments from the U.S. Citizenship and Immigration
Services in the final report.
The report contains eight recommendations aimed at improving USCIS’
selection and oversight of physicians and its review of foreign
nationals’ medical forms. Your office concurred with the eight
recommendations and described corrective actions to implement them.
Based on information provided in your response to the draft report,
we consider recommendation 4 open and unresolved. As prescribed by
the Department of Homeland Security Directive 077-01, Follow-Up and
Resolutions for the Office of Inspector Genera
Based on information provided in your response to the draft report,
we consider recommendations 1 through 3 and 5 through 8 open and
resolved. Once your office has fully implemented the
recommendations, please submit a formal closeout letter to us
within 30 days so that we may close the recommendations. The
memorandum should be accompanied by evidence of completion of
agreed-upon corrective actions and of the disposition of any
monetary amounts.
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
[email protected]
[email protected]
Consistent with our responsibility under the Inspector General Act,
we will provide copies of our report to congressional committees
with oversight and appropriation responsibility over the Department
of Homeland Security. We will post the report on our website for
public dissemination.
Please call me with any questions, or your staff may contact Sondra
McCauley, Acting Assistant Inspector General for Audits, at
(202) 981-6000.
4 .
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29 .
Abbreviations
A-files Alien files .CDC Centers for Disease Control and Prevention
.CFR Code of Federal Regulations .HHS Health and Human Services
.INA Immigration and Nationality Act .ISO Immigration Services
Officer .LEIE List of Excluded Individuals and Entities .MQRR
Medical Quality and Risk Reduction .NPDB National Practitioner Data
Bank .NPWR National Processing Workflow Repository .OIG Office of
Inspector General .
U.S.C.
U.S.C.
www.oig.dhs.gov
www.oig.dhs.gov
www.oig.dhs.gov
OIG-18-78
U.S. Citizenship and Immigration Services (USCIS) administers the
Nation’s lawful immigration system, safeguarding its integrity and
promise by efficiently and fairly adjudicating requests for
immigration benefits while protecting Americans, securing the
homeland, and honoring our values.
As part of its mission, USCIS reviews and adjudicates the
applications of foreign nationals who legally enter the United
States and want to adjust from a temporary status to a lawful
permanent resident status. USCIS has the authority to determine a
foreign national’s admissibility to the United States; according to
the Immigration and Nationality Act (INA), immigrants who seek to
adjust their status may be inadmissible based on health-related
grounds, which are designed to protect the health of the U.S.
pop
1
When applying for adjustment of status, foreign nationals are
required to undergo a medical examination by a physician whom USCIS
has designated as a civil surgeon. Physicians apply to USCIS for
designation as civil surgeons by submitting an Application for
Civil Surgeon Designation (Form I-910). Civil surgeons do not
determine a foreign national’s admissibility or eligibility for
immigration status adjustment; they perform the required medical
examination and report the findings on a Report of Medical
Exam
Prior to March 11, 2014, individual USCIS field offices were
responsible for determining whether a physician met the
requirements to be designated as a civil surgeon. When the program
was centralized in March 2014, USCIS “grandfathered” more than
4,200 civil surgeons, thereby allowing them to maintain their
designation without completing a Form I-910 for further
verification. Since March 11, 2014, Immigration Services Officers
(ISO) at USCIS’ National Benefits Center review and adjudicate
Forms I-910.
8 United States Code (U.S.C.) § 1182(a)(1)
8 United States Code (U.S.C.) § 1182(a)(1)
1
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Figure 1 shows USCIS’ process for designating physicians as civil
surgeons.
Figure 1. USCIS’ Process for Designating Civil Surgeons, as of
March 11, 2014
Figure
Source: Department of Homeland Security Office of Inspector General
(OIG) representation of USCIS data
Foreign nationals who legally enter the United States may apply to
adjust to lawful permanent resident status by submitting an
Application to Register Permanent Residence or Adjust Status (Form
I-485) to USCIS.
ISOs at USCIS field offices and service centers review and
adjudicate applications for status adjustment. ISOs make the status
adjustment determination after reviewing the application (Form
I-485) and supporting documents, including the civil surgeon’s
report on the medical form. ISOs review the medical form to
determine whether the foreign national meets the health-related
standards for admissibility. The medical form should contain the
results of the civil surgeon’s medical examination and
documentation o
2 OIG-18-78
•.
•.
•.
•.
•.
•.
drug abuse or addiction.
Figure 2 shows USCIS’ medical form review process, which is used to
verify the medical admissibility of foreign nationals seeking to
adjust to lawful permanent resident status.
Figure 2. USCIS’ Medical Form Review Process
Figure
3 .OIG-18-78
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
In this report, we examine USCIS’ process for designating
physicians as civil surgeons and USCIS’ review of the medical forms
of foreign nationals applying to adjust to lawful permanent
resident status.
Results of Audit
Results of Audit
USCIS has inadequate controls for verifying that foreign nationals
seeking lawful permanent residence status meet health-related
standards for admissibility. First, USCIS is not properly vetting
the physicians it designates as civil surgeons. We determined that
USCIS designated physicians with a history of patient abuse or a
criminal record as civil surgeons. This is occurring because USCIS
does not have adequate policies to ensure only suitable physicians
are designated as civil surgeons. Second, when revi
As a result of these deficiencies, USCIS may be placing foreign
nationals at risk of abuse by some civil surgeons. USCIS could also
be exposing the U.S. population to contagious or dangerous health
conditions from foreign nationals erroneously granted lawful
permanent resident status.
USCIS Does Not Properly Vet Physicians It Designates as Civil
Surgeons
USCIS Does Not Properly Vet Physicians It Designates as Civil
Surgeons
In vetting physicians who apply to become civil surgeons, USCIS
neither ensures the physicians meet eligibility requirements for
designation as civil surgeons, nor has it prevented physicians with
a history of patient abuse or criminal records from being
designated as civil surgeons. In addition, USCIS allowed physicians
to remain civil surgeons without verifying that they met
eligibility requirements, and it does not always promptly revoke
the designation of noncompliant civil surgeons. These
deficiencies
USCIS Does Not Ensure Physicians Meet Civil Surgeon Eligibility
Requirements
USCIS Does Not Ensure Physicians Meet Civil Surgeon Eligibility
Requirements
The INA gives USCIS the authority to designate civil surgeons to
conduct medical examinations of foreign nationals seeking
immigration benefits, and the Code of Federal Regulations (CFR)
provides general requirements for determining civil surgeon
eligibility. According to the INA and the CFR, only licensed
physicians with at least 4 years of professional experience may
be
2
designated as civil surgeons. The USCIS Policy Manual (policy
manual) provides more specific requirements for determining civil
surgeon eligibility. According to the policy manual, an application
for civil surgeon designation must contain:
3
a completed Form I-910; proof of U.S. citizenship, legal status, or
authorization to work in the United States; a copy of the
physician’s medical degree verifying he or she is a Doctor of
Medicine or Doctor of Osteopathy;
. a copy of the physician’s current full and unrestricted medical
license in the state in which he or she seeks to perform
immigration medical examinations; and
. evidence to verify the requisite professional experience, such as
letters of employment verification.
USCIS ISOs do not ensure that the physicians’ applications they
review comply with requirements in the INA, CFR, and the policy
manual. Specifically, we statistically sampled and reviewed 135
I-910 files of civil surgeons approved by USCIS between March 11,
2014, and June 30, 2017. For 19 of these 135 files (14 percent),
USCIS did not have the evidence to prove a physician met the
qualifications for a civil surgeon, with several of the 19 files
missing more than 1 piece of evidence. Table 1 shows the
eviden
Table 1. Evidence Missing from 19 I-910 Files of Approved Civil
Surgeons
Type of Evidence Missing from File
Type of Evidence Missing from File
Type of Evidence Missing from File
Number of Files with Evidence
TR
Missing*
5
2
6
1
9
Source: DHS OIG analysis of reviewed I-910 files *The number of
files adds up to more than 19 because some files were missing more
than 1 type of evidence.
Based on the results of our statistical sample, approximately 14
percent of the 1,337 civil surgeon designations, or an estimated
188 designations of the civil surgeon designation population, made
between March 11, 2014, and June 30, 2017, may lack evidence to
support USCIS’ decision to designate the physician as a civil
surgeon.
USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B
USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B
3
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
These I-910 review process deficiencies occurred because USCIS does
not provide formal training to ISOs responsible for adjudicating
civil surgeon applications and does not require second-level
reviews. According to USCIS officials, one reason they do not
provide formal training is that only 1 or 2 ISOs are assigned to
review about 50 civil surgeon applications a month.
USCIS Designates Civil Surgeons Who May Put Foreign Nationals’
Health and Safety at Risk
USCIS Designates Civil Surgeons Who May Put Foreign Nationals’
Health and Safety at Risk
In addition to designating physicians who may not meet eligibility
requirements, USCIS failed to prevent physicians with a history of
patient abuse or a criminal record from being designated as civil
surgeons. We attribute this failure to inadequate reviews of
physicians’ histories. Specifically, USCIS does not require ISOs to
consider medical board disciplinary history before designating
physicians as civil surgeons.
Of USCIS’ 5,569 active civil surgeons, 132 could pose a health or
safety risk to foreign nationals seeking to adjust their status. We
identified 11 civil surgeons, active as of June 30, 2017, who had
been excluded by the Department of Health and Human Services (HHS)
OIG from participating in federally funded health care programs for
various offenses. These 11 physicians were on HHS OIG’s List of
Excluded Individuals and Entities (LEIE), a public list of
individuals and entities excluded from participation i
4
Table 2. Offenses of Physicians Excluded from Federally Funded
Health Care Programs
Number of Civil Categories of Excludable Offenses Surgeons
Conviction relating to program or health care fraud 1 Default on
health education loan or scholarship 2 Federal or state health care
program exclusion or suspension 4 Patient abuse or neglect
conviction 1
Program-related conviction 3
Program-related conviction 3
11
funded health care programs
Source: DHS OIG analysis of LEIE as of July 2017 and active civil
surgeons as of June 30,
Source: DHS OIG analysis of LEIE as of July 2017 and active civil
surgeons as of June 30,
There were 5,569 total active civil surgeons as of June 30, 2017. 6
OIG-18-78
4
www.oig.dhs.gov
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Additionally, state medical boards have disciplined 121 active
civil surgeons for offenses that may meet HHS OIG’s criteria for
exclusion. Twenty-nine of the 121 civil surgeons had disciplinary
actions for egregious infractions. These offenses include felony
conviction for solicitation of capital murder and engaging in
dishonest, gross, and repeated negligent conduct in patient care
and treatment. Although some disciplinary conduct may have occurred
years ago, the nature of the offense may continue to rende
. A physician in Georgia with a felony conviction for solicitation
of capital murder because he attempted to hire a hit man to kill a
dissatisfied patient in Houston, Texas. The California,
Pennsylvania, and Texas Medical Boards subsequently revoked his
license for the criminal conviction. However, the Georgia Medical
Board allowed the physician to resume his practice several years
later.
. A physician with a history of professional sexual misconduct and
exploitation of female patients from a position of power,
authority, and trust. The Texas Medical Board restricted his
license for 5 years and the physician was not allowed to be alone
with female patients while conducting physical examinations.
. A physician disciplined by the California Medical Board for
numerous offenses, including allowing her medical assistants to
dilute mumps, measles, rubella, and varicella vaccines; pre-draw
vaccines; administer injections with less than effective needles;
give free vaccines to ineligible patients; falsify medical records;
and other unprofessional behaviors.
Although Federal laws and regulations give USCIS discretion in
designating physicians as civil surgeons, the component has
established only minimal eligibility requirements for physicians.
When they are determining whether to designate a physician as a
civil surgeon, USCIS does not require ISOs to consider a
physician’s medical board disciplinary history. Rather, USCIS
officials said ISOs only check the status of the medical license
the physician provided in the application. To guard against risking
the hea
DHS has a resource USCIS could use to better monitor physicians who
apply for designation as civil surgeons. The Medical Quality and
Risk Reduction Branch (MQRR) in DHS’ Workforce Health and Safety
Division is responsible for protecting national security and
mitigating liability by ensuring employees, detailees, and
contractors have the qualifications and other credentials (e.g.,
licenses) necessary to perform medical services for, or on behalf
of, DHS.
7 .OIG-18-78
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
MQRR uses the National Practitioner Data Bank (NPDB) to verify and
continuously monitor medical provider credentials, including
qualifications, licensure information, and other relevant health
care provider data. Figure 3 shows the type of information captured
in the NPDB.
5
Figure 3. Types of Information in the National Practitioner Data
Bank
Figure
https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp
https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp
2018)
USCIS could use MQRR’s access to the NPDB to assess the suitability
of physicians who apply to become civil surgeons. MQRR could notify
USCIS of
Congress created the NPDB as an information clearinghouse, with the
primary goals of improving health care quality, protecting the
public, and reducing health care fraud and abuse in the United
States.
5
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
physicians who may not meet DHS suitability standards and may pose
a risk to foreign nationals or national security.
USCIS Allowed Civil Surgeons to Maintain Their Designation without
Verifying Their Eligibility
USCIS Allowed Civil Surgeons to Maintain Their Designation without
Verifying Their Eligibility
Prior to March 11, 2014, USCIS field offices designated physicians
as civil surgeons. In March 2014, USCIS centralized the civil
surgeon program and introduced the I-910 process, at which time the
component “grandfathered” more than 4,200 civil surgeons, thereby
allowing them to maintain their designation without verifying they
met eligibility requirements. According to USCIS officials, these
civil surgeons were not required to complete a Form I-910.
6
Our review of 25 active grandfathered civil surgeon files showed
that USCIS did not have the evidence necessary to support their
designations. Specifically, USCIS did not have a file to support
the designation of 4 of the grandfathered civil surgeons, and all
21 of the remaining civil surgeon files were missing 1 or more
types of evidence required by the policy manual. Table 3 shows the
evidence missing to support the grandfathered civil surgeon
designations.
7
Table 3. Evidence Missing from 25 Grandfathered Civil Surgeon
Designations
Table 3. Evidence Missing from 25 Grandfathered Civil Surgeon
Designations
Type of Evidence Missing
Type of Evidence Missing
Type of Evidence Missing
Proof of authorization to work in the United States
Proof of authorization to work in the United States
10
17
3
21
4
Source: DHS OIG analysis of reviewed grandfathered civil surgeon
files *The number of files adds up to more than 25 because some
files were missing more than 1 type of evidence.
This deficiency occurred because, prior to March 11, 2014, when
field offices were designating physicians as civil surgeons, USCIS
did not have formal policies requiring evidence to support their
designation. Also, when the designation process was centralized,
USCIS officials stated they did not ask the more than 4,200
grandfathered civil surgeons to provide evidence verifying they met
the eligibility requirements.
We did not include USCIS’ decision to grandfather civil surgeons
designated prior to the initiation of the I-910 process in the
scope of this audit and take no position on the legality or
propriety of USCIS’ decision. USCIS Policy Manual, Volume 8, Part
C, Chapter 2, Section B
We did not include USCIS’ decision to grandfather civil surgeons
designated prior to the initiation of the I-910 process in the
scope of this audit and take no position on the legality or
propriety of USCIS’ decision. USCIS Policy Manual, Volume 8, Part
C, Chapter 2, Section B
6
7
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
USCIS Did Not Take Prompt Action against Civil Surgeons Who Failed
to Maintain a Current and Unrestricted Medical License
USCIS Did Not Take Prompt Action against Civil Surgeons Who Failed
to Maintain a Current and Unrestricted Medical License
Revoking a physician’s designation as a civil surgeon makes him or
her ineligible to conduct immigration-related medical examinations.
According to the policy manual and Form I-910 instructions, USCIS
may revoke a civil surgeon’s designation for several reasons,
including failure to:
maintain a currently valid and unrestricted license to practice as
a
physician in any state in which the physician conducts
immigration-related
medical examinations; comply with Centers for Disease Control and
Prevention (CDC) Technical
Instructions for Panel Physicians and Civil Surgeons (technical
instructions);
8
and
continue to meet the professional qualifications required for civil
surgeon
designation, engaging in immigration fraud, or otherwise engaging
in
activity that poses a risk to public health or safety. According to
USCIS
regulations, a form's instructions are incorporated into the
regulations
requiring its submission [8 CFR §103.2(a)(1)].
In reviewing a report that USCIS received in May 2017 on active
civil surgeons, we identified 48 civil surgeons, who were not in
our statistical sample and whose medical license was either expired
or restricted. Although USCIS received the report in May 2017,
several months elapsed before the component revoked the
designations of 37 of the 48 civil surgeons. For the 37 civil
surgeons, USCIS revoked 1 designation in July 2017, 34 designations
in August 2017, and 1 designation in November 2017. As of
December
9
USCIS did not promptly revoke these designations because its
process for identifying civil surgeons with inactive or restricted
medical licenses is inefficient. According to USCIS officials, to
determine whether civil surgeons should maintain their designation,
USCIS checks the status of their medical license using a
contractor, Evercheck, which is only required to verify medical
license information on active civil surgeons biannually (every 6
months). Further, one ISO is responsible for manually
reviewing
CDC’s Technical Instructions for Panel Physicians and Civil
Surgeons are on the CDC website .and include instructions on
recording findings from the medical examination and on
.vaccinations, medical history, and communicable diseases.
(See.
CDC’s Technical Instructions for Panel Physicians and Civil
Surgeons are on the CDC website .and include instructions on
recording findings from the medical examination and on
.vaccinations, medical history, and communicable diseases.
(See.
8
(last visited June 15, 2018).. One civil surgeon voluntarily
relinquished the designation in August 2017. .
(last visited June 15, 2018).. One civil surgeon voluntarily
relinquished the designation in August 2017. .
surgeons.html,
https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil
9
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
because the biannual report contains medical license information
for more than 5,500 civil surgeons.
In addition to using the NPDB to monitor physicians applying to
become civil surgeons (as noted previously), the NPDB may be
another resource to monitor civil surgeons’ medical licenses. MQRR
could notify USCIS of negative actions against civil surgeons’
medical licenses reported in NPDB, and this information could
facilitate USCIS’ revocations.
USCIS’ Review of Medical Forms Is Inadequate
USCIS’ Review of Medical Forms Is Inadequate
As part of adjudicating applications to adjust to lawful permanent
resident status, ISOs review medical forms to verify foreign
nationals meet health-related standards for admissibility. We
reviewed 151 statistically sampled Alien files (A-files) of foreign
nationals whom USCIS had approved for lawful permanent resident
status. We identified errors in 44 of the medical forms in these
A-files. Some errors were caused by ISOs accepting incomplete and
inaccurate medical forms. In other cases, the forms were co
10
instructions.
11
These deficiencies occurred because USCIS did not adequately train
ISOs on proper review of medical forms and USCIS did not enforce
its existing policy, which requires ISOs to return inaccurate
medical forms to the foreign national for corrective action. Also,
USCIS does not review and track errors on medical forms to monitor
how well civil surgeons comply with CDC’s technical instructions.
As a result, USCIS cannot be certain the civil surgeons actually
administered all required tests and vaccinations and
ISOs Accepted Incomplete and Inaccurate Medical Forms
ISOs Accepted Incomplete and Inaccurate Medical Forms
When adjudicating foreign nationals’ status adjustment
applications, ISOs are required to determine a foreign national’s
medical admissibility based on the information in the medical form.
According to USCIS policy, when determining medical admissibility,
ISOs must ensure medical forms are legible, complete, valid, signed
and dated, and placed in a sealed envelope. If these requirements
are not met, ISOs must return the medical form to the foreign
national for
A-files are the official files for immigration and naturalization
records created or consolidated for non-U.S. citizens. We
attributed some of the same errors on medical forms to two or even
three causes. For example, an ISO may have accepted an incomplete
or inaccurate form, in which the civil surgeon also failed to
follow CDC’s technical instructions. For this reason, the number of
errors we identified exceeds the number of medical forms.
10
11
OFFICE OF INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
corrective ISOs may suspend their decision on the adjustment of
status until a complete and accurate medical form is resubmitted.
Also according to the policy manual, ISOs may grant a waiver for
certain vaccinations, for example, if the foreign national has had
a severe allergic reaction to a vaccination.
action.
12
In 32 of 151 A-files reviewed, ISOs did not comply with USCIS
policy when reviewing medical forms and accepted incomplete or
inaccurate medical forms. We identified the following errors:
. 19 medical forms missing vaccination information or in which the
civil surgeon marked the wrong box on the vaccination portion of
the form.
. 5 medical forms missing required medical tests, such as tests for
.gonorrhea or syphilis. .
. 7 medical forms with various errors, such as the form was not
signed by an active civil surgeon, the form had expired (requiring
a new form), the civil surgeon signed the form before receiving
test results, the civil surgeon did not verify the foreign
national’s identity, or the form did not contain the required stamp
from a health department.
. 1 medical form in which the civil surgeon’s information was not
legible.
Based on our statistical sample results, from October 2013 through
May 2017, USCIS may have approved about 330,000 of 1,558,031
adjustment of status applications population with inaccurate or
incomplete medical forms. These errors may have rendered the
foreign nationals medically inadmissible.
This acceptance of invalid medical forms occurred because USCIS
does not adequately train ISOs on reviewing medical forms to
determine whether the foreign national meets health-related
standards for admissibility. When hired, USCIS provides new ISOs
with fewer than 2 hours of training focused on health-related
admissibility standards or on reviewing medical forms — out of 200
total training hours. For ISOs reviewing applications that do not
require an in-person interview, USCIS provides up to 5 hours of
tot
ISOs Did Not Verify That Active Civil Surgeons Completed Medical
Forms
ISOs Did Not Verify That Active Civil Surgeons Completed Medical
Forms
USCIS policy requires foreign nationals’ medical forms be signed
and dated by an active civil surgeon who conducted the medical
examination, but